Family Says NHS Trust ‘Should Have Done More to Prevent Suicidal Man’s Death’

Father-Of-Three Took His Own Life During Period Of Home Leave

03.07.2012

The heartbroken family of a man who was allowed to leave a psychiatric ward on the day he committed suicide have spoken of their horror after a coroner found there were ‘a series of failures which contributed to the circumstances of his death.’

Expert medical lawyers at Irwin Mitchell representing the relatives of Craig Dore, of Totley, Sheffield, said the mistakes made in 2010 were unacceptable but said they welcome the fact the Trust has since carried out an investigation and made changes to prevent similar incidents happening again.

Mr Dore, a father-of-three, had been suffering severe depression and anxiety for eight months before he jumped from the M1 Tinsley viaduct on 29 December 2010.

A week-long inquest into his death heard how the 49-year-old was allowed to leave a psychiatric ward at the Michael Carlisle Centre, part of Nether Edge Hospital and run by Sheffield Health and Social Care NHS Foundation Trust (SHSC), unaccompanied on the morning of his death, despite previously attempting to take his own life on two separate occasions before he was admitted.

HM Coroner for South Yorkshire Christopher Dorries, who recorded the cause of death as multiple injuries caused by the fall, said the proper procedures were not followed to ensure Mr Dore could not leave the ward before an assessment of his mental health.

He said: “Adequate steps were not taken to protect Mr Dore from a real and immediate risk to his life. Mr Dore’s absence was recognised shortly after he left but there was a lack of necessary intervention in that no steps were taken either to warn Mrs Dore of the situation or otherwise recover Mr Dore safely.”

Following the inquest, Mr Dore’s wife Jillian, said: “We are glad that the coroner took our concerns about the care Craig received at Nether Edge Hospital seriously. We often felt sidelined by staff at the hospital who didn’t fully understand Craig’s condition. Although he continued to tell them he was feeling well we told them otherwise and felt we weren’t being taken seriously.

“Although it is too late for Craig, we feel re-assured the Trust has also investigated Craig’s death thoroughly and just hope that they have improved things at the hospital to help other vulnerable patients in future.
“We are relieved the inquest is now over so that we can try and get our lives back on track. Craig was a fantastic dad and devoted husband, father, brother and son who we miss desperately.”

The court heard that, on the morning of Mr Dore’s death, staff on the ward were aware that the shower rail in his room had collapsed and a ceiling tile had been disturbed exposing a beam, which could have been used to hang himself.

But, despite these obvious concerns, Mr Dore was allowed to leave the ward that morning before he could be seen by doctors. His absence was discovered shortly after by staff on the ward but they didn’t make any effort to warn Mrs Dore of the situation or bring him safely back to hospital.

The inquest heard that Mr Dore’s depression and anxiety began in April 2010 after he became concerned he was suffering from a serious illness, which proved to be unfounded.

Mr Dore, with support from his family, sought help from his GP and was referred to the Improving Access to Psychiatric Treatment Service in Sheffield.

Despite receiving help from the service, Mr Dore attempted suicide for the first time on 7 December 2010 by taking an overdose of tablets and was referred for further intensive community based care. He then tried to hang himself on 18 December.

Mr Dore was eventually arrested and detained at the Burbage Ward at Nether Edge Hospital under the Mental Health Act after he absconded to Skegness, Lincolnshire, and was found carrying a knife.

The hospital allowed him home leave with his wife and children, despite his family’s concerns about his vulnerability and intentions to harm himself. His daughter Javvina contacted the hospital twice on 21 December about her concerns that her father was still at risk and was not telling staff the truth about how he really felt. The court heard that opportunities to speak to Mrs Dore alone were missed and therefore staff at the hospital were not made fully aware of how bad previous home visits had gone.

Arrangements were made by staff at the Burbage ward for Mr Dore to remain under supervision until the review has been completed, however, these restrictions were not communicated to staff properly and he was allowed to leave.

He briefly visited his wife Jillian at home but locked her in the family’s downstairs toilet before driving to the M1 Tinsley viaduct, where he took his life.

Mr Dore, a butcher, had been married to wife Jillian for 29 years and leaves behind children Javvina, Jamaine and Jason plus four grandchildren.

Ian Murray, a medical law specialist at Irwin Mitchell, representing the family, said: “We are grateful to the coroner for investigating Mr Dore’s death and are relieved SHSC has learnt important lessons from this tragedy and has improved communications to ensure the welfare of other patients are safeguarded in future.

“It is clear that Mr Dore was vulnerable and, following previous attempts to harm himself, it should have been apparent that his leave on 29 December 2010 should not have gone ahead. His family trusted staff at the centre to care for their husband and dad and are frustrated and angry about the fact he was allowed leave.

“His family feel that more should have been done to protect him after staff were alerted to his previous attempts to take his own life.”